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Abstract

Introduction:

Influenza and COVID-19 vaccination rates remain suboptimal, demanding new community-centric approaches that improve targeted counseling and increase vaccine uptake. Notably, racially diverse communities show high vaccine hesitancy, yet most existing vaccine studies focus on white, college-educated cohorts.

Objective:

Here, we identify factors influencing vaccination decisions of patients at Turtle Creek Primary Care clinic in Turtle Creek, PA, a racially-diverse borough.

Design:

A retrospective mixed-methods study of the predominantly non-white patient population at Turtle Creek Primary Care clinic, a clinic caring for >70% minority patients.

Results:

Fourteen factors emerged that patients reported were crucial to vaccine decision-making. Of these factors, top reasons for COVID-19 vaccine hesitancy were trust in vaccines, vaccine side effects, perceived vaccine knowledge, and faith/religion. Top reasons for influenza vaccine hesitancy were perceived need, vaccine side effects, trust in vaccines, and habitual behaviors. We also uncovered correlations between vaccine decision factors and sociodemographic factors. Participants > 65-years-old were more likely to cite personal safety in choosing to get the COVID-19 vaccine, while non-white participants were more likely to cite others’ safety. Participants > 65-years-old were also more likely to cite personal safety in influenza vaccine decision-making, and non-female participants were more likely to cite perceived need for influenza vaccines.

Conclusions:

These data uncover targetable factors contributing to vaccine hesitancy and aid in developing community-centered, personalized vaccine education approaches in Turtle Creek and analogous minority communities.

Keywords

vaccine hesitancy flu COVID-19 health equity community perceptions

Introduction

Vaccination efforts against the COVID-19 pandemic are punctuated with discussions of vaccine hesitancy. Many patients remain hesitant about receiving vaccines despite expert consensus that mass vaccination is essential, with COVID-19 vaccines reported to have prevented 18 million hospitalizations and 3 million deaths in the past 2 years.¹ Increased vaccine hesitancy has been associated with a perceived dearth of safety data, increasing distrust of experts, frequent changes in policies, and floods of new information.^2,3 Of note, certain patient demographics have been associated with increased vaccine hesitancy, such as people age under 65, not having a college degree, identifying as black or biracial, and living in southern states.^4
-6 This implores healthcare providers to evaluate and understand the concerns of many distinct populations.

Vaccination against influenza remains a public health crisis as well. Influenza vaccines were reported to prevent 105,000 flu-related hospitalizations in 2019 to 2020 and lower risk of death from flu by 31%, highlighting the necessity of vaccination.⁷ Yet, vaccine uptake rates are consistently below the “herd immunity” threshold, even among healthcare-affiliated populations.⁸ Like COVID-19, influenza vaccination rates are often lowest amongst racial minorities. For example, black and Hispanic healthcare employees report lower vaccination rates than their white peers.⁹ For healthcare systems wanting to reduce mortality from preventable infectious diseases, it is crucial to gain a better understanding of COVID-19 and influenza vaccine hesitancy.

Many studies have evaluated initiatives that attempted to assuage hesitant patients and boost vaccination rates. Unfortunately, most of these interventions have not shown strong efficacy. For example, a multicenter trial examined if receiving information from racially-matched experts would influence hesitant patients’ COVID-19 vaccine uptake, but it did not increase uptake compared to non-racially matched controls.¹⁰ Various randomized control trials have attempted to increase hesitant patients’ COVID-19 vaccine uptake via personalized text message reminders,¹¹ government “debunking” campaigns,¹² culturally-matched expert testimonies,¹³ personally addressed emails,¹⁴ or multimodal educational approaches.¹⁵ None of these interventions were able to demonstrate a robust increase in uptake compared to controls.

The failure of many pro-vaccine interventions poses the question: What have current research studies failed to uncover about hesitant patient populations? For one, many were based on hypothesized extrapolations of previously successful studies. We need more information about how patients and healthcare providers interact in the era following the COVID-19 pandemic. Second, most focused on populations with white, college-educated predominance and neglect populations that express the highest vaccine hesitancy, namely underrepresented racial minorities. It is imperative that future studies account for the hesitations of racially and economically diverse populations.

This study focused on the population at the University of Pittsburgh Medical Center (UPMC) Turtle Creek Primary Care clinic, a population of racially diverse and socioeconomically disadvantaged patients who are often overlooked in other large vaccine hesitation studies and recently characterized by our group last year.¹⁶ To our knowledge, this study is the first to evaluate the reasoning behind vaccine hesitancy amongst a distinct, racially-diverse population of western Pennsylvania.

Methods

The study design and survey were approved by the Quality Improvement Review Committee at the University of Pittsburgh Medical Center (UPMC). Projects reviewed and approved by the UPMC Quality Improvement Review Committee do not meet the federal definition of research according to 45 CFR 46.102(l) and do not require additional Institutional Review Board (IRB) oversight.

Study Design and Data Collection

A retrospective mixed-methods study focusing on community perceptions of COVID-19 and influenza vaccines at Turtle Creek Primary Care clinic was conducted from August to October of 2021. Detailed study methods have previously been published,¹⁶ and are briefly described here.

A random number generator was used to identify 400 patients from the Turtle Creek Primary Care clinic’s patient database. Contact information for these patients was curated by the Turtle Creek clinic manager. Authors made up to 3 attempts to contact patients by their listed phone number using the Doximity Dialer displaying the clinic’s phone number. Authors were able to contact 176 participants, of which 123 consented to and completed the survey.

The full survey questionnaire and answer options are reported in Online Appendix A1. This study focuses on responses to the 2 open-ended survey questions asking reasons for COVID-19 and influenza vaccine decisions (Online Appendix, questions 5 and 7).

Statistical Analysis

Binning of vaccine outcome and sociodemographic variables

Sociodemographic variables were discretely binned to guide statistical analysis and interpretation (Table S1). Age was binned into 4 brackets (in years): 18 to 24, 25 to 44, 45 to 64, and >65. Gender was dichotomized as (1) Female, and (2) Not Female. Race was binned into 3 categories: (1) Black or African American (2) White, and (3) Other Race. Education was trichotomized into (1) some high school to high school diploma or GED, (2) Associate’s degree to some college, and (3) Bachelor’s degree completion or above.

Coding of free-text responses for reasons of vaccination status

Qualitative thematic analysis was used to characterize trends among responses. Surveyors first recorded participants’ responses to the question as free text. Initial analysis of these free text responses elucidated 14 common elements described in a code book (Table S2). This code book depicts 14 reasoning variables, their operational definitions, and corresponding examples from the collection of responses. Using this code book, free text responses were anonymized and underwent blinded coding by 2 or more authors to assess which, if any, of the 14 factors were mentioned.

Bivariate associations

Categorical data are reported as counts (number of responses) or frequency (percent of total survey responses). Comparisons between categorical variables were done using chi-square test. All tests are 2-tailed and statistical significance set at alpha = 0.05. All statistical analyses are done using IBM SPSS Statistics (Version 27) predictive analytics software.

Role of the Funding Source

No funding source was obtained or used in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript.

Data Availability

The datasets analyzed during the current study are available from the corresponding author on request.

Results

Of 2556 patients that receive care at Turtle Creek Primary Care clinic, 400 patients were randomly selected to be surveyed. Of these, we successfully contacted 176 (44.0%) patients, and 123 (30.8%) consented to participate in the survey. 115 (28.8%) respondents completed survey questions related to influenza vaccination, and 109 (27.3%) completed survey questions related to COVID-19 vaccination (Figure 1A). Based on participants’ free-text responses when asked their reason for vaccine acceptance or hesitancy/refusal, fourteen distinct factors emerged as integral to their decision-making. Each of these factors clustered into 4 overarching themes of trust, need, safety, and availability (Figure 1B).

Figure 1.

(A) Flow chart representation of study design. Four hundred randomly selected patients at Turtle Creek Primary Care clinic were contacted, with 123 participants consenting to the study. Of these, 109 participants completed all survey questions related to the COVID-19 vaccine, and 115 participants completed all survey questions related to the influenza vaccine. (B) Thematic analysis of participant’s free text responses of rationale for choosing whether to get vaccinated, revealing 14 principal factors and 4 overarching themes of trust, need, safety, and availability.

We next assessed which of these 14 factors are most associated with COVID-19 vaccine acceptance versus hesitancy. Of participants who responded that they received or plan to receive the COVID-19 vaccine, the top reasons cited for doing so were personal safety (26.9%), other people’s safety (17.9%), job (14.9%), and comorbidities (13.3%) (Figure 2A). COVID-19 vaccine acceptance was further stratified into responses of “already got” or “plan to get” the vaccine (Figure 2B). Those who already got the vaccine also mentioned being influenced by previous COVID-19 infection, advice from others, and perceived need. Meanwhile, those who planned to get the COVID-19 vaccine mentioned perceived trust in vaccines and faith/religion. Of participants that have not gotten the COVID-19 vaccine or have no plans to get it, the top reasons cited for doing so were perceived trust in vaccines (28.6%), vaccine side effects (19.0%), perceived knowledge of vaccines (14.3%), and faith/religion (9.5%) (Figure 2C). COVID-19 vaccine hesitancy was further stratified into those that have not gotten the vaccines but will “maybe” get it and those that have “no plans” to get vaccinated (Figure 2D). Only those who will “maybe” get the COVID-19 vaccine cited being influenced by advice from others, comorbidities, personal safety, and access in their decision-making. Yet, those who have no plans to get vaccinated alone only mentioned faith/religion and perceived need.

Figure 2.

(A) Pie chart representation of top factors associated with COVID-19 vaccine acceptance. Legend depicts frequency of COVID-19 vaccine-accepting participants that cite the mentioned factor in their decision-making. n = 67 (B) Factors associated with COVID-19 vaccine acceptance shown both overall (left) and stratified by frequency of participants having gotten versus planning to get the COVID-19 vaccine citing the mentioned reason (right). n = 67 (C) Pie chart representation of top factors associated with COVID-19 vaccine hesitancy. Legend depicts frequency of COVID-19 vaccine-hesitant or refusing participants that cite the mentioned factor in their decision-making. n = 42 (D) Factors associated with COVID-19 vaccine hesitancy shown both overall (left) and stratified by frequency of participants that will maybe get versus have no plans to get the COVID-19 vaccine citing the mentioned reason (right).

We also assessed which factors are most associated with influenza vaccine acceptance versus hesitancy. Of those that stated they routinely get the influenza vaccine, the top reasons mentioned were personal safety (39.7%), comorbidities (17.0%), and advice from others (11.3%) (Figure 3A). Influenza vaccine acceptance was stratified into those that “always” get it and those that get the vaccine “most years” (Figure 3B). Only those that get the flu vaccine most years mentioned access or vaccine side effects in their reasoning to not receive the vaccine every year. Of participants that rarely or never get the influenza vaccine, the top reasons mentioned for doing so were perceived need (37.1%), vaccine side effects (25.8%), perceived trust in vaccines (12.9%), and habits & traditions (8.1%) (Figure 3C). Influenza vaccine hesitancy was stratified into those that get the vaccine “few years” or those that “never” get vaccinated (Figure 3D). Those that get vaccinated every few years also mentioned comorbidities, advice from others, access, and job as factors in their decision-making.

Figure 3.

(A) Pie chart representation of top factors associated with influenza vaccine acceptance. Legend depicts frequency of influenza vaccine-accepting participants that cite the mentioned factor in their decision-making. n = 53 (B) Factors associated with influenza vaccine acceptance shown both overall (left) and stratified by frequency of participants that get the influenza vaccine always versus most years citing the mentioned reason (right). n = 53 (C) Pie chart representation of top factors associated with influenza vaccine hesitancy. Legend depicts frequency of influenza vaccine-hesitant or refusing participants that cite the mentioned factor in their decision-making. n = 62 (D) Factors associated with influenza vaccine hesitancy shown both overall (left) and stratified by frequency of participants that get the influenza vaccine few years versus never get it citing the mentioned reason (right).

Furthermore, we sought to assess correlations between factors involved in COVID-19 vaccine decision-making and sociodemographic groups, in hopes of aiding clinicians to develop community-centric, personalized vaccine counseling and education at the Turtle Creek Primary Care clinic (Table S3; Figure 4). Participant age was significantly associated with citing personal safety in vaccine decision making (χ² = 14.552, P = .002), with those of older age being more likely to mention personal safety (Figure 4A). Additionally, gender was associated with citing comorbidities (χ² = 6.411, P = .011), with those identifying as female being less likely to mention comorbidities (Figure 4B). Race was associated with citing other people’s safety in vaccine decision-making (χ² = 10.858, P = .004), with those identifying as non-white being more likely to mention this factor (Figure 4C). Race was also associated with citing personal safety, although this trend was not statistically significant (χ² = 5.371, P = .068), with white participants being more likely to mention personal safety as a factor (Figure 4D).

Figure 4.

(A-D) Chart representation showing bivariate associations of factors associated in COVID-19 vaccine decisions and sociodemographic groups. Chi-square test was used for all analyses. Values and significance for each analysis are shown. Data are reported as frequency of participants either citing or not citing the factor of interest. Age is bracketed by: ages 18 to 24, 25 to 44, 45 to 64, and > 65. Race is bracketed by: Black/African-American, white, or other race. Gender is bracketed by: female versus non-female respondents.

We similarly assessed correlations between influenza vaccine decision-making and sociodemographic groups (Table S4; Figure 5). Participant age was significantly associated with citing personal safety (χ² = 11.597, P = .009), with those of younger age being less likely to mention this factor (Figure 5A). Gender was significantly associated with citing perceived need in decision-making (χ² = 5.133, P = .023), with female participants being less likely to mention this (Figure 5B). Race was associated with citing vaccine side effects in decision-making (χ² = 5.761, P = .056), with white participants being more likely to mention vaccine side effects (Figure 5C). Additionally, race was associated with citing habits/traditions in vaccine decisions, although the trend was not statistically significant (χ² = 4.880, P = .087), with non-white participants being more likely to mention vaccination habits (Figure 5D).

Figure 5.

(A-D) Chart representation showing bivariate associations of factors associated in influenza vaccine decisions and sociodemographic groups. Chi-square test was used for all analyses. Values and significance for each analysis are shown. Data are reported as frequency of participants either citing or not citing the factor of interest. Age is bracketed by: ages 18 to 24, 25 to 44, 45 to 64, and > 65. Race is bracketed by: Black/African-American, white, or other race. Gender is bracketed by: female versus non-female respondents.

These analyses revealed top factors associated with COVID-19 or influenza vaccine acceptance or vaccine hesitancy, uncovering intriguing correlations between patient-described factors and sociodemographic groups at the Turtle Creek Primary Care clinic. Based on these data, we constructed a flow chart representation of primary reasons cited for vaccination decisions and vaccine counseling considerations based on patient demographics of the Turtle Creek community (Figure 6).

Figure 6.

Flow chart representation of COVID-19 and influenza vaccine education and counseling considerations in the Turtle Creek community based on study findings of top factors associated with vaccine acceptance versus hesitancy and associations between cited factors and sociodemographic groups.

Discussion

This study allowed for open-ended collection of patient hesitation toward COVID-19 and influenza vaccines and examined the most influential reasons why patients hesitated and/or refused to obtain these vaccines.

Only a handful of existing studies have acquired qualitative, open-ended data regarding individuals’ personal vaccine hesitations.^14,16
-18 A 2020 study aimed to engage with vaccine-hesitant healthcare workers through personally addressed emails, but unlike many other studies they collected open-ended data from participants regarding the specific reasoning behind their vaccine avoidance.¹⁴ The study uncovered over 19 unique reasons why respondents were hesitant to receive the COVID-19 vaccine, most notably concern about unknown risks of receiving a rapidly produced vaccine.¹⁴ Another study found 3 leading reasons for being hesitant toward COVID-19 vaccines to be lack of sufficient effectiveness evidence, perceived lack of disease risk, and vaccine safety concerns.¹⁹

Additionally, a 2021 study conducted by the authors of this paper which aimed to understand vaccine hesitancy in an underserved primary care clinic was able to identify 14 discrete reasons why patients chose to avoid COVID-19 and influenza vaccination.¹⁶ This study expands upon these 14 reasons to identify 4 overarching themes of trust, need, safety, and availability implicated in vaccine hesitancy. Moreover, we expand on previous findings by assessing the important associations between demographic characteristics and individual citations for vaccine hesitancy.

We anticipate our findings will inform the development of targeted and individualized vaccine interventions that will boost vaccination rates and decrease preventable infectious disease morbidity in our local communities.

In this study, we found compelling associations between sociodemographic factors and individually-cited factors for vaccine acceptance and hesitancy. For example, participants age 65+ were more likely to cite personal safety in their vaccination decision making, and they were also more likely to be vaccinated against COVID-19 and flu.¹⁶ This is in accordance with years of data collection that show older age and awareness of susceptibility due to age are correlated with vaccine acceptance.^20,21

Interestingly, regarding race and gender, the factors cited in vaccination decisions for COVID-19 and flu were quite different. When considering just COVID-19, non-white patients were more likely to cite other people’s safety as a reason to get vaccinated, while white patients were more likely to cite personal safety as a reason to get vaccinated. Meanwhile, for the flu vaccine, non-white patients were more likely to cite “habits & traditions” as a reason to not get vaccinated, while white patients were more likely to cite vaccine side effects as a reason to not get vaccinated. Patients of all races were emphatic in expressing safety concerns for themselves and their community. However, there was a stronger sense of community against people who identified as non-white that prompted them to cite other people’s safety as the primary reason to get vaccinated. This is aligned with global trends that have shown that populations who are largely non-white or live in a collectivist society share a common attitude about the social responsibility to be vaccinated against COVID-19.^22,23 One study found that countries with predominantly collectivist cultures such as China, India, Peru, and South Korea had greatest support for requiring vaccines, while support for mandatory vaccines was lowest in Poland, Russia, and Germany.²³ There are obvious nuances to this statement, with vaccine uptake often depending on availability of supplies and services, as low vaccination uptake was often seen in African countries.²³ Another study in the UK found that non-white ethnic groups in the UK were COVID-19 vaccine-hesitant despite being disproportionately affected by the virus, with the main citation being medical mistrust.²⁴ Specific drivers of hesitancy among minority racial groups often include mistrust of health authorities and inequitable or under-representation in vaccine trials.^25,26 This shows that despite some groups of patients feeling a sense of social responsibility to get vaccinated, a trustworthy alliance with patients is fundamental to overcoming vaccine hesitancy regardless of the country of origin.

When it came to the rationale for flu vaccines, a weaker sense of perceived disease prevalence and severity was noted. Across the US, the general population does not consider the flu to be a scary enough condition to vaccinate against, despite influenza being a disease with significant morbidity and mortality, especially amongst high-risk groups.²⁷ This concept mirrors the trend amongst childhood vaccinations like DTaP, rotavirus, and MMR falling out of favor. Experts believe that herd immunity has prevented the severe morbidity and mortality that these conditions can cause, sheltering the modern general population from seeing the horrific effects that can be avoided by vaccination.²⁸

There has been a growing body of literature describing vaccine hesitancy in various communities around the globe for all types of diseases, including COVID-19. In 2019, the World Health Organization (WHO) named “Vaccine Hesitancy” as one of the top 10 threats to global health.²⁹ With this knowledge, proposing educational interventions and policies to address vaccine hesitancy is critically important.

As emerging studies delineate variations in vaccine hesitancy amongst different communities, it’s important to study unique populations to deliver personalized interventions for each community. For example, vaccine hesitancy in a safety-net health system in Louisiana was characterized by concern for side effects, safety of the vaccine, and efficacy of the vaccine³⁰; meanwhile vaccine hesitancy in rural Pennsylvania was rooted in wariness due to the perception of speed of development of the mRNA indicating a lack of integrity in developing the vaccine and the politicization of oversight agencies reducing their trustworthiness.³¹ These slightly nuanced differences in vaccine hesitancy can help inform efforts to design trustworthy public health messaging about vaccines that are personalized to that community. As such, future directions of this work include similar factor-based analyses of vaccine hesitancy in other clinics serving minority communities of Pennsylvania, as well as intervention-based research employing targeted and personalized vaccine education strategies in Turtle Creek Primary Care clinic and subsequent clinical sites of study.

Our hope is that the findings of this study can guide local clinical decision-makers and perhaps even policymakers toward the close monitoring of vaccine uptake amongst subgroups at risk of vaccine hesitancy, control the spread of COVID-19 misinformation on social media, and focus on debunking COVID-19 vaccine myths. With emerging vaccines like the one for Respiratory Syncytial Virus (RSV) and the reaffirmed potential for unprecedented global impact of potentially vaccine-preventable illnesses, it is important to keep in mind the social implications vaccine hesitancy will have for current and future vaccination rollouts.³²

Supplemental Material

sj-docx-1-jpc-10.1177_21501319231212287 – Supplemental material for A Cross-Sectional Factor Analysis of COVID-19 and Influenza Vaccination Decisions in a Racially Diverse Western Pennsylvania Community

Supplemental material, sj-docx-1-jpc-10.1177_21501319231212287 for A Cross-Sectional Factor Analysis of COVID-19 and Influenza Vaccination Decisions in a Racially Diverse Western Pennsylvania Community by Jorna Sojati, Anjana Murali, Catherine Pressimone and Allie Dakroub in Journal of Primary Care & Community Health

Supplemental Material

sj-docx-2-jpc-10.1177_21501319231212287 – Supplemental material for A Cross-Sectional Factor Analysis of COVID-19 and Influenza Vaccination Decisions in a Racially Diverse Western Pennsylvania Community

Supplemental material, sj-docx-2-jpc-10.1177_21501319231212287 for A Cross-Sectional Factor Analysis of COVID-19 and Influenza Vaccination Decisions in a Racially Diverse Western Pennsylvania Community by Jorna Sojati, Anjana Murali, Catherine Pressimone and Allie Dakroub in Journal of Primary Care & Community Health

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Publication of this work was supported by the Research!America Civic Engagement Microgrant (awarded to JS, AM, CP).

ORCID iD

Jorna Sojati

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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